Module 4 discussion

  

ISBARR for Nurses

  

I-Introduce   Yourself: Introduce yourself and your role in the patient’s care

State the unit you are calling   from when speaking with a physician over the phone

 

S-Situation

Specify the patient’s name and   current condition or situation. Explain what has happened to trigger this   conversation

Patient   name: ____________________________ Room: ___________ Sex/Age: ___________

Diagnosis:   ____________________________________________________________________

 

B-Background:   State the admission date of the   patient, his or her diagnosis, and pertinent medical history. Give a brief synopsis of what’s been done so far   (e.g., lab test)

History:

Allergies:

Labs:

 

A-Assessment:   Give a summary of the patient’s   condition. Explain what you think the problem is or say, “I’m not sure what   the problem is, but the patient is deteriorating”. Expand upon your statement   with specific signs and symptoms.

Current VS: T: ______ P: _____   BP: ____/_____, RR: _____, O2Sat______ @ _________(O2)

Heart Rhythm:   ___________________________ Lugs sounds: ____________________

Blood Sugar: ____________ LOC:   __________________

 

R-Recommendation

Explain what you would like to   see done (e.g., lab tests, treatments, or “I need you to see the patient   now”) State any new treatments or changes ordered (e.g., monitoring   and frequency or when to re-notify the physician if there is no improvement   in the patient)

 

R-Read   Back: repeat any orders received   back to the prescriber for accuracy.